Healthcare Provider Details

I. General information

NPI: 1235047341
Provider Name (Legal Business Name): CRYSTAL MARIE GURROLA TALBOT L.AC., MSTOM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2026
Last Update Date: 08/31/2026
Certification Date: 08/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3958 N AVONDALE AVE
CHICAGO IL
60641-6245
US

IV. Provider business mailing address

929 CLARENCE AVE APT 1
OAK PARK IL
60304-2092
US

V. Phone/Fax

Practice location:
  • Phone: 773-245-3504
  • Fax:
Mailing address:
  • Phone: 708-655-0234
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number198.011992
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: